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INTEGRATING COMPLEMENTARY MEDICINE (CAM) INTO ALLERGY AND ASTHMA William S. Silvers, M.D. Clinical Professor of Medicine University of Colorado Health.

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Presentation on theme: "INTEGRATING COMPLEMENTARY MEDICINE (CAM) INTO ALLERGY AND ASTHMA William S. Silvers, M.D. Clinical Professor of Medicine University of Colorado Health."— Presentation transcript:

1 INTEGRATING COMPLEMENTARY MEDICINE (CAM) INTO ALLERGY AND ASTHMA William S. Silvers, M.D. Clinical Professor of Medicine University of Colorado Health Science Center

2 William S. Silvers, M.D. Financial:self-funded Research:only our own patient preferences Legal Consult/Expert Witness:none Organizational: Allergy Asthma Colorado PC Gifts:none Other:(someone’s gotta do this work w/o funding!)


4 What is CAM? NCCAM definition: …”a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”-

5 What is CAM? COMPLEMENTARY medicine: –used together with conventional medicine. –Aromatherapy to help lessen a patient's discomfort post surgery (ALLERGY: eucalyptus in the steam) ALTERNATIVE medicine: –used in place of conventional medicine. –S pecial diet to treat cancer instead of surgery, radiation, or chemotherapy. –(ALLERGY: acupuncture for asthma) The list of what is considered to be CAM changes continually New therapies that are proven to be safe and effective become adopted into conventional health care- NCCAM

6 What is CAM? INTEGRATIVE medicine (NCCAM) – Combines mainstream medical therapies and CAM (“Complementary” WSS) therapies for which there is some high-quality scientific evidence of safety and effectiveness. –ALLERGY: Yoga type breathing for asthma/VCD

7 Mind-Body Interventions Uses a variety of techniques to enhance the mind’s capacity to affect bodily functions and symptoms Meditation / prayer Patient support groups Cognitive-behavioral therapy Mental healing Art, music, dance –ALLERGY: Journaling for asthma –Stress/anxiety increase skin tests wheal response »stress and anxiety may enhance and prolong AR symptoms.

8 Biologically Based Therapies Uses substances found in nature, such a herbs, foods, and vitamins ALLERGY: Butterbur for AR, FAHF-2 (Food Allergy Herbal Formula-2) for peanut induced anaphylaxis Cold H2O fish for Omega-3 Fatty acids Vitamin D for Asthma

9 Manipulative and Body-Based Methods Based on manipulation and/or movement of one or more parts of the body –Allergy: Sinus accupressure? –ENERGY THERAPY Biofield therapies Bioelectromagnetic-based therapies

10 Energy Therapy Biofield therapies –Affect energy fields that purportedly surround and penetrate the human body –Forms of energy therapy include applying pressure and/or manipulating the body by placing hands Bioelectromagnetic-based therapies –Unconventional use of electromagnetic fields such as pulsed fields, magnetic fields, or alternating or direct current fields







17 Integrative Medicine Allergic Rhinitis Natural Medicines Comprehensive Database

18 NMCD- Natural Medicine Comprehensive Database Commonly Used Conventional and Natural Medicines for Allergic Rhinitis* Antihistamines Conventional Medicines Cetirizine (Zyrtec) Chlorpheniramine (Chlor-Trimeton) Desloratadine (Clarinex) Diphenhydramine (Benadryl) Fexofenadine (Allegra) Loratadine (Claritin, Alavert) Natural Medicines Grape seed extract (Vitis vinifera)Grape seed extract Pycnogenol (Pinus pinaster)Pycnogenol Vitamin C Decongestants Conventional Medicines Phenylephrine (Sudafed PE, etc) Pseudoephedrine (Sudafed, etc) Natural Medicines Bitter orange (Citrus aurantium)Bitter orange Ephedra (Ephedra spp.)Ephedra

19 NMCD- Allergic Rhinitis Corticosteroids Fluticasone (Flonase) Mometasone (Nasonex) Triamcinolone (Nasacort) Mast Cell Stabilizer Conventional Medicines Cromolyn (NasalCrom) Natural Medicines Quercetin Spirulina (Spirulina spp.)Spirulina Stinging nettle (Urtica dioica)Stinging nettle Leukotriene Inhibitors Conventional Medicines Montelukast (Singulair) Natural Medicines Butterbur (Petasites hybridus)Butterbur

20 NMCD- Allergic Rhinitis-other Miscellaneous Capsaicin Cat's ClawCat's Claw (Uncaria guianensis, Uncaria tomentosa) GoldensealGoldenseal (Hydrastis canadensis) MethylsulfonylmethaneMethylsulfonylmethane (MSM)MSM Nasal irrigation

21 Integrative Medicine Allergic Rhinitis Botanicals/Supplements Natural Medicines Comprehensive Database

22 Alternative Medicine Survey in a Private Allergy Asthma Practice-1998 1997- Eisenberg follow-up of 1993 NEJM 113 Questionnaires- 81 Denver, 32 Vail CAM discussed 18% of time w/ PCP or allergist 64% wanted to discuss CAM 16% saw CAM practitioners for gen’l health 4% pts saw CAM for allergies/asthma 10% PCPs regularly Rx CAM Denver v. Vail clinics- similar results

23 CAM ?aire f/u 1998-2004 Both study periods, similar majority wanted to discuss CAM (65%-69%) Similar 18% each yr discussed CAM w PCP Similar % pts sought CAM for gen’l med needs (16% v 19%) INCREASE from 4%-10% of our pts saw a CAM for allergies/asthma Similar 62% wanted to pursue combo traditional w/CAM w/i our practice – (27% did not know/doc’s choice)

24 CAM f/u ?aire 1998-2004 More pts seeking chiropractic (36% v 52%) Acupuncture 1 st CAM (48%) in 2004 surpassing vitamin/mineral Tx in 1998 IMPRESSED- CONCERNED re: 10% of OUR patients seeking CAM from outside our ofc Further INTEGRATIVE Allergy approach- evidence-based. Environ, diet, exercise, supplements, Breath relaxation- communication

25 CAM ?aire f/u: 2010 (N=100) In contrast to previous interest (65%+), only 44% wished to discuss CAM for allergies/asthma a decrease to 8% had PCPs who regularly recommend CAM

26 Immune Impact of Specific Herbs & Vitamins Vit D: shift Th1 to Th2, no effect MS, IBD Vit E: inhib prolif mast cc, eos in mucosa Vit A: hi levels shift Th1 to Th2 Vit C: antioxid, most evid no effect on asthma Magnolol: plant polyphenol, immun effects Quercetin: flavinoid, raspberries to apples Antiasthma herbal medicine intervent (ASHMI) FAHF-2 Resveratol: grape skin extracts, red wine. Ma Huang: ephedrine, banned 2004, CV effects

27 INTEGRATIVE Medicine: Immune Enhancement Echinacea –Adults: 200 mg three times a day for three weeks, then stop for one week and resume if still symptomatic Eucalyptus oil –For URI, oil can be added to a warm bath to help relieve nasal congestion

28 Diet Supplement & Health Education Act (DSHEA): Herbal Medicine DSHEA 1994: requires NO proof of efficacy or safety, FDA must prove product is unsafe Lack of standardization of active ingredients FDA establishes good manufacturing practice regulations but no formal regulatory oversight (contrast Germany, UK, Fr, Canada) Unanswered Questions that remain: – bioavailability, dosage, interlot variability, contaminants, adverse drug interactions

29 Butterbur Common use: allergic rhinitis, asthma, migraine headache Caution: cross reactivity w/ Ragweed family, crysanthemums, daisies, etc Hepatotoxic due to pyrrolizidine alkaloids

30 Echinacea Common use: URI May increase AR/C in patients with allergy to ragweed, chrysanthemums, marigolds, and daisies –NEJM 2005- no benefit with “colds”

31 Eucalyptus oil Common use: Asthma -> decongestant/expectorant Oral use may cause dyspnea, wheezing, cough, drowsiness Caution: patients with seizure disorder, heart disease, and acute intermittent porphyria Contamination with bacteria may worsen rhinoconjuctivitis and asthma

32 Ephedra (ma huaung) Common use: asthma, weight loss, and energy enhancement Hypertension, insomnia, arrhythmia, tremor, headache, seizure, cerbrovascular event, myocardial infarction

33 Evening primrose Common use: eczema, asthma, menopausal symptoms Contact dermatitis with use of oil on skin Cross reactivity with plants in the same family

34 Chamomile tea Common use: “calming” tea, relief of sore throat Worsening allergic rhinitis reported with allergy to plants in the same family (Echinacea, daisy, marigold)

35 Butterbur Common use: allergic rhinitis, asthma, headache, pain Caution: cross-reactivity w/ ragweed family,

36 Feverfew Common use: migraine headache, and rheumatoid arthritis Cross reactivity in patients allergic to chrysathemums, daisies, marigolds, or ragweed Atopic dermatitis reported with contact to skin Mouth inflammation, ulcers, lip edema, tongue irritation, loss of taste Long-term users may experience withdrawal symptoms including rebound headache, anxiety, difficulty sleeping, muscle stiffness, and joint pain

37 St. John’s Wort Common uses: depression, anxiety, insomnia, migraines, IBS, sciatica GI disturbances, fatigue, dizziness, dry mouth, photosensitivity Should not be used with SSRIs Inducer of cytochrome P-450 leading to altered metabolism of drugs co- administered with herbal supplement

38 CAM use in practice: Case #1 Symbiotics – Clostrum Nature’s Way – Flax seed Oil Super Cignan NeilMed Sinus Rinse Emer’gen- C Mixed Berry Enzymatic Therapy – acidophilis pearls Clear Mountain Air – Ding Chuan Wan Natural Factors – Learning Factors Daily Nutrient Boost Smoothie Mix Garden of Life – Primal Defense Garden of Life – Perfect Food Super Green Formula Garden of Life – Q-Zyme A comprehensive evaluation was conducted and a thorough review of herbals and supplements included:

39 Clear Mountain Air Teapills (Ding Chuan Wan) [MW3317] Regular Price: $13.00 Our Price: $11.70 Also known as: Calm Wheezing Pills Packaging: 200 pills Recommended Dosage: 8 teapills, 3 times per day Traditionally used for cough with chest tightness or wheezing with thick yellow phlegm. Clears heat, resolves phlegm, stops cough, sinks the qi. THIS PRODUCT CONTAINS EPHEDRINE GROUP ALKALOIDS IN THE FORM OF HERBAL EXTRACTS. WE ARE UNABLE TO SHIP THIS PRODUCT TO CALIFORNIA ADDRESSES. WARNING: NOT FOR USE BY INDIVIDUALS UNDER THE AGE OF 18 YEARS. DO NOT USE IF PREGNANT OR NURSING. Consult a physician or licensed qualified health care professional before using this product if you have, or have a family history of, heart disease, thyroid disease, diabetes, high blood pressure, depression or other psychiatric condition, glaucoma, difficulty in urinating, prostate enlargement, or seizure disorder, or if you are using a monoamine oxidase inhibitor (MAOI) or any other dietary supplement, prescription drug, or over-the-counter drug containing ephedrine, pseudoephedrine, or phenylpropanolamine (ingredients found in certain allergy, asthma, cough or cold, and weight control products). Do not exceed recommended serving. Exceeding recommended serving may cause serious adverse health effects, including heart attack and stroke. Discontinue use and call a physician or licensed qualified health care professional immediately if you experience rapid heartbeat, dizziness, severe headache, shortness of breath, or other similar symptoms. Individuals who are sensitive to the effects of caffeine should consult a licensed health care professional before consuming this product. KEEP OUT OF REACH OF CHILDREN.

40 On-line Resources NCCAM: Epocrates: http://epocrates.com PDR: http://pdr.net Natural Medicines Comprehensive Database: / NIH Office Dietary Supplements: FDA Patient Safety News:


42 J Allergy Clin Immunol Vol 123, 2, Feb 2009 Clinical Reviews in Allergy and Immunology –CAM: Herbs, phytochemicals and vitamins and their immunologic effects, Mainardi et al –Efficacy and mechanisms of action of traditional Chinese medicines for treating asthma and allergy, Xiu- Min Li et al –CAM for the allergist-immunologist: Where do I start?, Engler et al –Role of CAM in the field of allergy and clinical immunology, Sampson –Letter to editor: CAM educ: Need for expanded educ resources for AAAAI mbrs, Engler, Silvers, Bielory –Prenatal probiotic admin can influence Bifidobacterium development in infants at hi risk of allergy, Lahtinen et

43 Food Allergy Herbal Formula-2 silences peanut-induced anaphylaxis for a prolonged post-treatement period via IFN-g-producing CD8+ cells, JACI 2009;123, 443-51 Srivastava, Qu, Zhang, Goldfarb, Sampson, Xiu- Min Li, MSSM, NY 9 Herb formula Pnut specif IgE decr 50% IgG2a incr by 60% TH2 cytokine by CD4+ T cells decr 75% CD8+ T cell IFN-g prod incr by 85%. Neutraliz IFN-g and deplet CD8+ T cells decr FAHF-2 effic



46 Drug-CAM Interactions

47 CAM-Associated Anaphylaxis

48 CAM-Associated Angioedema

49 Integrative Therapy Environmental –Humidifier/dehumidifer, HEPA filters –Dust mite precautions, dander minimization –Nasal saline Pharmaceuticals –Oral antihistamines –Topical nasal steroids, nasal antihistamines –Mucolytics Immunotherapy

50 Integrative Summary Consultation Environment: nasal saline, humidity, hepa Nutritional Advice: –AvoidanceEnhancement Supplements: Exercise: Breathing Relaxation: Mental-Emotional-Social-Spiritual Health- (takes time- for future visits, other providers?)

51 Integrative Summary Consultation Environment: nasal saline, humidity, hepa Nutritional Advice: –AvoidanceEnhancement Supplements: Exercise: Breathing Relaxation: Mental-Emotional-Social-Spiritual Health- (takes time- for future visits, other providers?)

52 Integrative Therapy Botanicals –Butterbur- leaf extract dose 8mg TID, whole root extract dose 50mg BID –Bioflavonoids- Quercetin- 1000-2000mg QD to TID –Stinging nettle (Urtica dioica)- 300mg BID Supplements –Multivitamin, vitamin C, (vitamin E?) –Vitamin D- 2000+ IU QD –Probiotics- Lactobacillus GG- pregnancy/infants- 1-10 billion units TID to QID 2-4 weeks pre delivery and continue 3-6 months during breastfeeding. Culturelle now Every Day Health –Grape Seed Extract

53 Integrative Therapy Nutrition –Yogurt, omega-3 fatty acids (cold H2O fish) Biomechanical therapies –Diaphragmatic breathing –Steam inhalation (a little eucalyptus?)

54 CAM: What’s the Science? Conclusions Be Conscious: CAM is here (w/ patients) –Bielory, Engler: Annals Allergy –Sampson: JACI Feb 2009 Communicate: What is patient using?? –Eisenberg, NEJM Investigate:CAM adv effects, Drug Inter –Know resources- online, PDA Integrate:Art & Science of Medicine »



57 Historical Overview per Dr Len Bielory 2000 B.C.E. –“Here eat this root” 1000 C.E. –“That root is heathen. Here say this prayer” 1850 C.E. –“That prayer is superstition. Here drink this potion.” 1940 C.E. –“That potion is snake oil. Here swallow this pill.” 1985 C.E. –“That pill is ineffective. Here take this antibiotic.” 2002 C.E. –“That antibiotic is artificial. Here, eat this root!”

58 Thank You’s Len Bielory MD Renata Engler MD Robert Harvey MD Hugh Sampson MD Gailen Marshall MD My staff, My patients You- the audience


60 Mind-Body Medicine Psychoneuroendocrinology. 2009 Jun;34(5):670- 80. Epub 2009 Jan 15. How stress and anxiety can alter immediate and late phase skin test responses in allergic rhinitis. Kiecolt-Glaser JK, Heffner KL, Glaser R, Malarkey WB, Porter K, Atkinson C, Laskowski B, Lemeshow S, Marshall GD.Kiecolt-Glaser JKHeffner KLGlaser R Malarkey WBPorter KAtkinson CLaskowski BLemeshow SMarshall GD


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